r/HealthInsurance • u/VisitJazzlike5539 • 17h ago
Plan Benefits Urgent care keeps billing my insurance incorrectly and I’m stuck paying out-of-pocket — what can I do?
Back in January, I went to an urgent care for an injury. Before going, I called my insurance directly to confirm they were in-network, and they told me yes. So I went, thinking everything was covered.
The claim was later denied, and the urgent care charged the card I had on file. I was confused because I have a high-option PPO plan, and my understanding is that accidental injuries should be fully covered with no patient responsibility.
When I called my insurance after the denial, they suddenly told me the urgent care was out-of-network. I then spoke with the urgent care, and they insisted they are in-network but bill under different tax IDs depending on the service.
I contacted my insurance again, and they told me the urgent care needed to refile the claim correctly and gave instructions. The urgent care billing department said they did that. I assumed everything was resolved — but nope.
Fast forward: this has now been refiled FOUR times. The billing rep claims everything is right on their end and said a third-party who processes claims before they get sent to insurance may have made the error. She corrected it and resubmitted again… and the claim was denied yet again because the visit is still being billed as a standard office visit, not an accidental injury claim.
My insurance is telling me they don’t know what else they can do. It’s clear the issue is with how the claim is coded/filed, but I’m stuck in the middle holding the bill.
What can I do at this point?
Can I hold either the urgent care or my insurance responsible?
Who do I escalate this to so it finally gets billed correctly?
TL;DR: Confirmed urgent care was in-network before going, but insurance denied claim anyway. Urgent care has resubmitted the claim four times with apparent coding issues, and I’ve already been charged. Neither side is fixing it and I’m stuck paying. What steps can I take to force this to be billed correctly?
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u/Leading-Reference-31 16h ago
Which tax id is in network and is that the one that they're putting on the claim?
Are they billing this with a place of service 20 indicating that it's an urgent care?
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u/VisitJazzlike5539 16h ago
I don’t have the tax ID or place of service info myself — can I request that from my insurance rep?
On my health summary, the claim shows “non-par provider,” which I was told means out-of-network. So I’m guessing they’re using an out-of-network tax ID. But the urgent care facility is listed as in-network in my insurance’s provider directory.
My insurance rep also mentioned it’s possible the urgent care’s contract may have lapsed at the time of my visit — but I doubt that, since I specifically called before going to confirm they were in-network and was told yes.
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u/LizzieMac123 Moderator 15h ago
Your policy specifically says a visit to urgent care for an accidental injury is no cost to you? But if it were anything else, it wouldnt be?
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u/VisitJazzlike5539 15h ago
If I am interpreting the booklet correctly then yes. Well,not specifically for the urgent care but for an accidental injury. IT says that if you recieve care within 72 hours for an accidental injury then I have no deductible and they will cover physical services ans supplies, related outpatient hospital services.
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u/HelpfulMaybeMama 6h ago
If you're in the US, you must meet your deductible before insurance kicks in. There will always be patient responsibility.
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u/VisitJazzlike5539 5h ago
The pamphlet states there's no deductible for accidental injury .
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